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Home My WebLink AboutMINUTES - 01062009 - C.13 (11) CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION JANUARY?0,6;2009,,• Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. n you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), . �tl, 1OlJtj given Pursuant to Government Code AMOUNT: $10,000.00 r ,ter tr�TY SOUNSEL Section 913 and 915.4. Please note all i.A"ON.Z t "Warnings". CLAIMANT: PRISCILLA LEVINE-HARRIS ATTORNEY: UNKNOWN DATE RECEIVED: DECEMBER 04, 2008 ADDRESS: 5029 MARTIN STREET, BY DELIVERY TO CLERK ON; DECKER 04, 2008 OAKLEY, CA 94561 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DECEMBER 04, 2008 . DAVID TWA, r Dated: By: Deputy 1I. FROM: County Counsel TO: Clerk of the Board of S eryisors ( ffhis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Boardcannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). O Other: Dated: /Z—��I� b� By: ,f Deputy County Counsel III. FROM: Clerk of the Board TO:,` County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. PDARD ORDER: By unanimous vote of the Supervisors present: (yY This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date o 2 �AVID TWA, CLERK, By Deputy Clerk WA ING(96v. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated 2a AVID TWA,CLERK, By Deputy Clerk This warning does not apply to claims which are not subject to the California Fort Claims Act such as actions in.inverse condemnation actions for specific relief such as map`damus or injunction, or Federaltivil Rights claims. The above list is not exhauitive.and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its;rights under California Tort Claims Act ;y jnar 6e.it waive rights under the statutes of limitations,applicable to actions not subject to the California Tort Claims Act l BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez,CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each. public entity. I ! - E. Fraud. See penalty for fraudulent claims, Penal-Code Sec. 72 at the end of this form. aaaaa a aaaaa■a■■■■■■■■■■■■■■a■ca■■■■■■■02a■■■■■■'0 a a E K 2 a 5 a a a%K s t a t■•9 99 a a a c t a Claim By: Reserved for Clerk's filing stamp P2i_SJJA- Against the County of Contra Costa or ) oEe 0 c�F9Kso- District) CpN,., Cp SU''FRV (Fill in the name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 10, OD6 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) ! 11a A4— 1� '2. Where did the damage or injury occur? (Include city and county) � �5�' • �yti � 3. owid the damage or injury occur? (Give full details;use extra paper if required)T 1 a 4_ 6S� &q.40 U1\40an PAKZeWyXA_ 10 4� O_F_ b 4. What particular act or omission on the po county or district officers, servants, or employees caused the injury or damage? 1v 0 V 15 t b•� $ j 0_�- a cGNwy oy� 5 Aujm (G Ut-px o 5 What are the names of county or district officers, servants, or employees causing the damage or injury? 6: TWLot damage or injuries do your claim resulted? (Give full extent of injuries or damages qairaed. gazh two estimates for auto damage.) �p �pt�c ) �� t� RC1 - 5 ' 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) CL---V— � , 8. Names and addresses of witnesses, doctors, and hospitals: ' � aJ S m 0"YvaY,-r&-,. k15' 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ■ ONMax5..t.....Oman a%MORE a nn as■■nano na■.aanaan■nnoaa■■ananaa aaanaaau a a a naaaaa.aanal ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his be " SEND NOTICES TO: (Attorney) ) Name and address of Attorney ) J04 i\S (Claimant's Signature) (Address) 1 Telephone No. ) Telephone No. a a,a.anommmo own Nunn SEEMS SUE aaannnaaaa aaaaaaa■a.aa Man■anon a a.aa..aal PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ...........o.....a.a Room a.......aaaaaa non■■enaaaaanonnnana aaaaaa aaannnaa■on a aoaaaaoal NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. Levine, Priscilla A(MR# 110008758303) Data Source: KP NCAL NB MASTER- REGNN13M After',V.Wt SuMmall. - PATIENT FrlscIlia A Levine lMRN110008758303) ..................... .... ........ ............ Visit Information .......... Provider;;:rov it t VD8. Te.9 Dept`:Phorte `: 11/13/2008 10:45 PM LANCE ALAIN GEE brv-Micl >Antioch Main MD Your Primary Care Providers Provider er -- PCP Type NINA Y. LEE MD OB/GYN Physician IRINA BRONSTEIN MID General Instructions and Follow-Up Patient Instructions You hurt your back, shoulder, and toes from tripping on curb. The xrays were negative for the toes but you problably have degenerative changes in your back that made it hurt more. Take the extra strength vicodin and muscle relaxer as needed for pain. Use ice for shoulder, back, and toes. See regular doctor next week if not better especially the shoulder. Visit Summary Vitals - Last Recorded B Pulse Sp02 Breastfeeding? 158/96 69 100% Yes Medications Prescriptions Ordered During This Visit . ........... ............ ..... End: KETOROLAC TROMETHAMINE 30 MG/ML [NJ SOLN 1 0/0 11/13/2008 11/14/2008 Sig: INJECT 30 MG INTRAMUSCULARLY NOW—FOR BACK OFFICE USE Class: Back Office Route: Injection HYDROCODONE-ACETAMINOPHEN 7.5-500 MG ORAL 10 1/1 11/14/2008 TAB Sig: TAKE 1 TABLET ORALLY 3 TIMES A DAY Class: Fill Now Route: Oral Non-formulary Exception Code: Treatment Failure METHOCARBAMOL 750 MG ORAL TAB 30 1/1 11/14/2008 Sig: TAKE 1 TABLET ORALLY 3 TIMES A DAY AS NEEDED FOR MUSCLE SPASM Class: Fill Now Route: Oral. Pharmacy Pharmacy iaiame< ............. ..... ........... .................. . ........ ... DRV SAND CREEK MOB Pharmacy Address and Hours Atldress Hours:: 4501 Sand Creek Road N Hours ANTIOCH, CA 94531 Orders Printed by Gee, Lance 11/14/08 12:17 AM Page 1 of 2 Levine, Priscilla A(MR#110008758303) Data Source: KP NCAL NB MASTER - REGNNBM Orders (continued) Orders Placed During This Visit Future Class Expires RADIOLOGIC EXAM, FOOT, COMPLETE, 3+ VIEW. Normal 1/31/10 Scheduling Instructions: Radiology will follow standard protocols according to clinical history. RADIOLOGIC EXAM, FOOT, COMPLETE, 3+ VIEW. Normal 1/31/10 Scheduling Instructions: Radiology will follow standard protocols according to clinical history. XR LUMBOSACRAL SPINE, AP AND LATERAL Normal 1/31/10 . Scheduling Instructions: Radiology will follow standard protocols according to clinical history. APPLICATION OF BRACE Back Office 1/31/10 Allergies Allergies as of 1111312008 Date Reviewed: 11/13/2008 (No Known Allergies) Appointment Information Future Appointments- Date Time Visit TypeDeparfrnent;; Proditler Length None. Printed by Gee, Lance 11/14/08 12:17 AM Page 2 of 2 C01UNTYOF CONTRA COSTA REPORT EVERY ACCIDENT _ 1 AS SOON AS POSSIBLE TO: i PUBLIC LIABILITY ACCIDENT Risk Management Division (OTHER THAN AUTOMOBILE) 2530 Arnold Dr.,Ste.#140 Martinez, CA 94553 (925)335-1440 DATE OF ANT TIME A THEg ACCIDENT PLA E F&tT O qOO 5-7 O )ESCRIPTIO OF OG ACCIDENT �� vGTldx.� I 17-16 5fNP, ALM -c!9(D- I N sc!�t ✓ TREAt ' V LoAfLTHE WHAT Wj INJURREEDD�DO MUM'SRT? /�- INJURY !I� �v W M --LAK/. I O TAKENAETER ACCID NS,T?.�K 0/ i OWNER TELEPHONE � PROPERTY KINDOF PROPERTY AND EXTENT OF DAMAGE DAMAGE ESTMiATED COST O%REPAIR j TELEPHONE ' /Vl I NAME ADDRESS TELEPHONE j WITNESSES NAME ADDRESS TELEPHONE i i TATE OE REPORTING PARTY SIGNATURE OF SUPERVISOR DEPARTMENT TO BE COMPLETED BY INVESTIGATOR DAZE COMPLAINANT S STATEMENT It ^ ' ' � !' rr,,. COUNTY'S I a{In`J, I/'�1�//J// INVESTI- ST I H 1 ER AIM WILL BE MADE - GATIONUT OF REMARKS AND RECOMMENDATIONS. ACCIDENT POLICY REPORT? WHERE